Optometric Physician



Vol. 23, #15  •   Monday, April 18, 2022


Off the Cuff: How to Fail at Treating Dry Eye Without Really Trying

I am not a big fan of telemedicine. I don’t mind it as a patient, but considering that my practice is essentially limited to dry eye and ocular surface disease, I really need to be hands on—especially with new patients. However, when an old friend emailed asking for help for one of his coworkers and the only option was telemedicine, I quickly agreed. It sounded like the patient was in pretty bad shape.

A few days later I received a text message from the 30-year-old co-worker, who introduced herself and offered a brief description of the issues she was having. She had seen five practitioners since recently relocating from California to the Southeast, and was in tears as she shared that none of the doctors were able to help her. Even worse, from her perspective, none seemed to really care.

She described being treated using a cornucopia of therapies, many that struck me as more random than logically thought out. She had little idea why she was prescribed or being treated with any of these things. Procedures like punctal occlusion were repeated despite not helping and after significant adverse reactions to earlier failed attempts.

It was easy to sense how scared she was and impossible to not feel badly for her. I reassured her and started by asking her to describe how she felt and when her symptoms were worst, the specifics of what was bothering her, and when things worsened or improved. I asked what medications she had been prescribed and what procedures she had undergone. For complex procedures like IPL, I asked her to describe the technique used in detail.

Thankfully she was a good observer and was able to communicate results of most of the testing and treatment that had been performed. None of the several anti-inflammatories used worked, suggesting that inflammation wasn’t a likely, or at least a primary, cause. She had clearly been undertreated with IPL, and many of the other approaches completely missed the mark. With this information, I spent about 15 minutes explaining the likely cause of her issues and then proposed a treatment plan.

I don’t have the space to describe the entirety of my recommendations or my rationale, but some problems were glaring. It was obvious that she had poor nocturnal lid closure. She had to pry her eyes open on waking. I recommended a non-petrolatum-, paraffin-based ointment. One of her main concerns was lid irritation, redness and swelling. I told her to stop using detergent-based lid scrubs, as they strip natural oils from the lids and periorbital skin and irritate more than help. I advised her to substitute hypochlorous acid solution sprayed onto her closed lids after gently cleansing with a wet, warm, soft washcloth.

Perhaps because she was a friend of a friend or just a patient in need, I spent a lot of time on that call. It wasn’t until the end of the conversation that I realized my impact. She said with an almost excited tone, “Dr. Epstein, you’ve spent more time with me than any other doctor I’ve seen and its obvious you actually care about me. I feel so much better. Thank you so much.”

Our skills and our knowledge vary, but the one consistent thing that helps patients is the ability to communicate that we care about them and that we give them enough time to actually be heard. Listening and caring are ultimately the foundations of clinical success.



Arthur B. Epstein, OD, FAAO
Chief Medical Editor

Want to share your perspective?
Write to Dr. Epstein at artepstein@optometricphysician.com. The views expressed in this editorial are solely those of the author and do not necessarily represent the opinions of Jobson Medical Information LLC (JMI), or any other entities or individuals.




Wearing Face Masks and Possibility for Dry Eye During the Covid-19 Pandemic

This population-based, observational, cross-sectional survey was conducted to investigate the relationship of increased face mask usage in the coronavirus disease (COVID-19) era with mask-associated dry eye (MADE). Participants aged six to 79 years old with formal school education were selected. All participants finished the 19-item questionnaire online, distributed through different social media platforms.

Of the 6925 participants who submitted eligible questionnaires, MADE was reported in 547 participants, which included 419 participants who developed new dry eye symptoms after wearing face masks and 128 participants whose pre-existing dry eye symptoms worsened with mask wearing. Longer time of face mask wearing, nonstandard wearing of face masks, reduced outdoor time, decreased daily reading time, shortened visual display terminals time, and dry environment were positively associated with MADE. There were significant associations between perceived MADE and age, female sex, education, use of glasses and contact lenses, and pre-existing dry eye. MADE was more common in adults ages >20 years than those ages ≤20 years or juveniles.

Given that MADE incidence increased, standard wearing of face masks was suggested as a protective factor for MADE. Researchers wrote that awareness about the possible risks of the condition should be created and clinical dry eye signs verified.

SOURCE: Fan Q, Liang M, Kong W, et al. Wearing face masks and possibility for dry eye during the COVID-19 pandemic. Sci Rep. 2022 Apr 13;12(1):6214.




Cost Burden of Endothelial Keratoplasty in Fuchs Endothelial Dystrophy: Real-World Analysis of a Commercially Insured US Population (2014-2019)

This study assessed the incremental burden of corneal transplant surgery for US commercially insured patients with Fuchs endothelial corneal dystrophy (FECD) treated with endothelial keratoplasty (EK) compared to controls. The study design was retrospective cohort using IBM® MarketScan® claims (January 2014 to September 2019) and included EK-treated (n=1562) and control patients (n=23,485) having ≥12 months' enrollment before and after diagnosis, who were subsequently matched on select characteristics. The index date was the beginning of the preoperative period (three months before EK); synthetic EK index was assigned for controls. All-cause, eye-disease, and complication-related healthcare resource utilization (HCRU) and costs were compared up to 36 months post index. For a small subset of patients, patient data were linked to the Health and Productivity Management supplemental database, which integrates data on productivity loss and disability payments.

Matched cohorts included 804 EK-treated and 1453 controls with average ages of 65.7 years; 1383 (61%) were female. Over 12 months of follow-up, all-cause ($41,199 vs. $20,222, p<0.001) and eye-disease related costs ($22,951 vs. $1389, p<0.001) were higher among EK-treated patients than controls. The cost differential increased additionally by $1000 to $2000 per annum by 36 months of follow-up. While balanced at baseline, over follow-up, EK-treated patients had higher prevalence of glaucoma, elevated intraocular pressure, cataract, cataract surgery, diagnosis of corneal transplant rejection, and retinal edema. By 36 month of follow-up, EK-treated patients had nine more short-term disability days, resulting in $2992 additional burden of disability payments.

Investigators found a higher cost burden among FECD patients receiving EK treatment vs. those who did not. As a result, they suggested that a change of management strategy could serve as an important benchmark for future studies.

SOURCE: Dhaliwal DK, Chirikov V, Schmier J, et al. Cost burden of endothelial keratoplasty in fuchs endothelial dystrophy: real-world analysis of a commercially insured US population (2014-2019). Clin Ophthalmol. 2022; Apr 6;16:1055-67.



Secondary Macular Holes Post Pars Plana Vitrectomy

This study was conducted to report the incidence, clinical presentation, and treatment outcome of full-thickness macular hole (FTMHs) diagnosed post pars plana vitrectomy. Researchers retrospectively reviewed the demographics, best-corrected visual acuity (BCVA), indication for the primary vitrectomy, time to diagnose the secondary FTMH, optical coherence tomographic (OCT) appearance, and treatment outcome of FTMHs, occurring after vitrectomy performed between January 2019 and December 2020.

Six of 523 vitrectomized eyes developed FTMHs, an incidence of 1.1%. The study included five females and one male, with mean age of 56.5 years (range 37-85). The indication for primary vitrectomy was rhegmatogenous retinal detachment (RRD) in three eyes, one eye each for sub internal limiting membrane hemorrhage from a ruptured macroaneurysm, vitreous hemorrhage from polypoidal choroidal vasculopathy (PCV), and pre-insertion of Ahmed glaucoma drainage device (GDD). FTMHs occurred within one week to three months after vitrectomy (time from primary vitrectomy to the identification of the secondary MH was a mean of 1.03 months). Mean BCVA in all six MH eyes was logMAR 0.9 (Snellen: 6/54). Anatomical closure was achieved after one surgery in three eyes, two surgeries in one eye, and after photodynamic therapy (PDT) in the PCV eye; one patient declined surgery. The mean BCVA in the four surgically closed MH eyes improved marginally from logMAR 0.82 (Snellen: 6/38) to logMAR 0.72 (Snellen: 6/30), with a mean follow-up of 7.6 months.

Researchers wrote that post-vitrectomy FTMH is rare, and RRD was the most common indication for initial vitrectomy. They observed that all secondary MHs were closed successfully using the inverted internal limiting membrane (ILM) flap technique, with limited improvement in vision. They added that the visual outcomes of the secondary MHs in this study reportedly were worse than those of idiopathic MHs.

SOURCE: Okonkwo ON, Akanbi T, Agweye CT. Secondary macular holes post pars plana vitrectomy. Int Med Case Rep J. 2022; Apr 5;15:141-55.






Industry News

Bruder Introduces New In-Office Package Options

Responding to demand from eye care professionals, Bruder recently introduced two new in-office package options for its moist heat eye compresses. A new small-footprint box and counter facilitate display of the Bruder Eye Compress in high-traffic, point-of sale locations. Learn more.






Prevent Blindness Announces Jenny Pomeroy Award Recipient

Prevent Blindness announced the recipient of the 2022 Jenny Pomeroy Award for Excellence in Vision and Public Health as VOSH/International. Read more.

Aurion Raises $120 Million

Aurion Biotech secured a $120 million financing. The company’s first candidate is a cell therapy for the treatment of corneal edema secondary to endothelial dysfunction. Read more.















Journal Reviews Editor:
Shannon Steinhauser, OD, MS, FAAO

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